Giving Birth With a Midwife in Attendance: Associations of Race and Insurance Status With Continuity of Midwifery Care in Philadelphia.

INTRODUCTION: From 2013 to 2019, Black women comprised 73% of pregnancy-related deaths in Philadelphia. There is currently a dearth of research on the continuity of midwifery care from initiation of prenatal care through birth in relation to characteristics such as race/ethnicity and income. The aim of this study was to investigate whether race/ethnicity and insurance status were associated with the likelihood of a pregnant person who begins prenatal care with a midwife to remain in midwifery care for birth attendance. METHODS: This was a retrospective cohort study of a diverse population of pregnant patients who gave birth in a large tertiary care hospital and had their first prenatal visit with a certified nurse-midwife (CNM) between June 2, 2009, and June 30, 2020 (n = 5121). We used multivariable, log-binomial regression models to calculate risk ratios of transferring to physician care (vs remaining within CNM care), adjusted for age, race/ethnicity, prepregnancy body mass index, insurance type, and comorbidities. RESULTS: After adjusting for pregnancy-related risk factors, non-Hispanic Black patients (adjusted relative risk [aRR], 1.14; 95% CI, 1.04-1.24) and publicly insured patients (aRR, 1.11; 95% CI, 1.01-1.22) were at higher risk of being transferred to physician care compared with non-Hispanic White and privately insured patients. Secondary analysis revealed that non-Hispanic Black patients had higher risk of transferring and having an operative birth (aRR, 1.35; 95% CI, 1.18-1.55), whereas publicly insured patients were at higher risk of being transferred for reasons other than operative births (aRR, 1.35; 95% CI, 1.18-1.54). DISCUSSION: These findings indicate that Black and publicly insured patients were more likely than White and privately insured patients to transfer to physician care even after adjustment for comorbid conditions. Thus, further research is needed to identify the factors that contribute to racial and economic disparity in continuity of midwifery care.

Primary language and the electronic health record patient portal: Barriers to use among Spanish-speaking adults with asthma.

OBJECTIVES: To assess electronic health record patient portal use among Spanish-speaking patients with asthma compared to English-speaking patients and identify barriers to use. METHODS: Using data collected for a PCORI-funded randomized controlled trial to increase patient portal use in low-income adults with uncontrolled asthma, we estimated the association between portal use, measured using surveys and actual user login data, and primary language. Open-ended survey responses were grouped into common themes. RESULTS: Among 301 adults with asthma: age 18-87, 90% female, 17% Spanish speakers; 44% had no portal use during the study. Spanish speakers were less likely to have ever heard of the patient portal than English speakers (p=.001) and reported more difficulty navigating the portal (p<.001). Spanish speakers with low health literacy had less portal use (31%) than their English-speaking counterparts (51%) (p=.02). Compared to high-literacy English speakers, the odds of using the portal for low-literacy Spanish speakers were 0.34 (95% CI 0.14, 0.84) (p=.02). Three-quarters of Spanish speakers cited barriers to portal use compared to one-quarter of English speakers, and many suggested creating a Spanish version to improve user-friendliness. CONCLUSIONS: English-only patient portals may not meet the needs of Spanish-speaking patients with uncontrolled asthma. Health systems serving Spanish-speaking communities should implement patient portals in Spanish.

Understanding clinician strategies for discussing driving fitness with patients: An initiative to improve provider-patient discussions about safe driving.

Objective: A frequently overlooked factor contributing to traffic crashes is driver medical conditions, including cognitive and physical impairments, which can compromise individuals' ability to drive safely. Clinicians are in a critical position (and often legally mandated) to identify patients with impairments that may affect their driving ability and counsel them on appropriate next steps. However, prior studies revealed that provider-patient discussions about driving occurred relatively infrequently and that clinician recommendations about when patients could resume driving varied substantially (Chen et al. 2008; Drazkowski et al. 2010). This research aimed to document current driver fitness assessment practices among neurology and neurosurgery clinicians at an academic medical center, with the overall purpose of informing quality improvement efforts.Methods: A cross-sectional, anonymous survey was distributed to physicians and advanced practice providers working in the neurosurgery and neurology departments of a large, Pennsylvania-based academic medical center. Survey question domains included: 1) frequency of discussions about driving, 2) comfort discussing driving with patients, 3) criteria used to assess patient fitness to drive, 4) driver rehabilitation program referral practices, and 5) Pennsylvania Department of Transportation (PennDOT) reporting.Results: The survey revealed that although most providers (68%) had high levels of perceived responsibility for counseling patients about driving, a minority regularly discussed driving issues with their patients (19% prior to discharge, 49% during clinic visits). In addition, only about half (54%) of providers reported having ever filed a report about a patient with the PennDOT, despite Pennsylvania's mandatory driver reporting law. Likelihood of PennDOT reporting was found to be strongly associated with provider knowledge of Pennsylvania unsafe driver reporting laws (p < 0.001).Conclusions: These findings highlight a need to enhance standard of care practices related to driver screening, counseling, and reporting. Overall, providers recognized the importance of their role in advising patients about safe driving and desired standardized protocols for guiding conversations about driving with patients, PennDOT reporting, and referring patients to driver rehabilitation services.

Local Extreme Heat Planning: an Interactive Tool to Examine a Heat Vulnerability Index for Philadelphia, Pennsylvania.

Exposure to extreme heat contributes to high morbidity and mortality relative to other climate hazards. The city of Philadelphia, PA is particularly vulnerable to the impacts of extreme heat, due to the urban heat island effect and high prevalence of sensitive populations. We developed a heat vulnerability index, which identified priority areas that are most at-risk of experiencing adverse heat-related health outcomes and in need of preparedness and mitigation interventions. An interactive website was created to display the maps and allow the public to navigate the data with links to potential resources for relief from extreme heat days. Such methods can be adapted for other cities that wish to identify and target long-term priority areas.

Understanding Parents' Perceptions of School-Based BMI Screening and BMI Report Cards Using Perceptual Mapping: Implications for School Nurses.

Half of U.S. states measure students' body mass index (BMI), with many communicating that information to parents through a "BMI report card" or notification letter. School nurses are usually responsible for implementing these programs and communicating results to parents. The purpose of this study was to understand parents' perceptions of BMI screening programs to help inform school nurses about messages that are most helpful to use in report cards to motivate parents to follow-up with a health-care provider or to make behavioral changes for their child. Using a cluster analysis and perceptual mapping methods, a commercial marketing technique that creates three-dimensional graphic maps, we identified four unique clusters of parents based on their core attitudes and beliefs related to BMI screenings and report cards. Based on vector modeling techniques, key message strategies were developed that can be used by school nurses to enhance parent response to a BMI report card.

African-American Parents' Knowledge and Perceptions About BMI Measurements, School-Based BMI Screening Programs, and BMI Report Cards: Results from a Qualitative Investigation and Implications for School-to-Parent Communication.

School-based body mass index (BMI) screenings can help parents make informed decisions about their child's health, but schools have questioned parents' understanding and attitudes about BMI measures and report cards. Although researchers have investigated minority parents' perceptions of their child's weight, no research has explored minority parents' knowledge and perceptions related to BMI measurements, school-based BMI screening programs, and BMI report cards. To address this gap, focus groups were conducted (n = 20) with female Black or African-American parents/guardians from a large urban school district. Participants were asked to share their perceptions before and after receiving education about BMI measurements and screening programs. Pre-education: Many participants had heard of BMI, thought it was similar to body fat, believed screenings were intended to track students' weights and monitor eating habits, and were concerned that screenings could cause their child embarrassment. Post-education: Most participants did not object to screenings, but said they would have without education about why and how BMI measurements are taken. They also voiced concerns about lack of prior notice, confidentiality, and the need for schools to serve healthier food. Some of these findings support those of other qualitative studies of parents' concerns about BMI screenings, but no previous studies have compared parents' perceptions of screening programs pre-/post-education. The results reinforce that schools' efforts to explain what BMI measurements are as well as why and how they are taken can increase parents' confidence in the schools and level of comfort with BMI screening programs and report cards.

A comprehensive review of school-based body mass index screening programs and their implications for school health: do the controversies accurately reflect the research?

BACKGROUND: Whereas legislation for body mass index (BMI) surveillance and screening programs has passed in 25 states, the programs are often subject to ethical debates about confidentiality and privacy, school-to-parent communication, and safety and self-esteem issues for students. Despite this debate, no comprehensive analysis has been completed that compares and contrasts how these issues differentially affect schools, parents, and students. METHODS: A keyword search from electronic databases and a review of state legislation related to BMI surveillance and screening were used to identify relevant literature and data focused on surveillance and screening policies, BMI report cards, and parental perceptions of BMI screenings and their child's weight status [corrected]. RESULTS: This article addresses the gap of previous literature by outlining the ethical considerations and implications that BMI screening programs and report cards have for schools, parents, and students, and links these with outcome studies to address whether these controversies are supported by research. CONCLUSIONS: Despite the controversies surrounding these programs, this review shows that they can be valuable for all parties and demonstrates BMI screening programs to be vital to the development of robust school-based obesity prevention programs and promotion of healthy lifestyles in schools.

Application of best practice approaches for designing decision support tools: the preparatory education about clinical trials (PRE-ACT) study.

OBJECTIVE: This article describes the rigorous development process and initial feedback of the PRE-ACT (Preparatory Education About Clinical Trials) web-based- intervention designed to improve preparation for decision making in cancer clinical trials. METHODS: The multi-step process included stakeholder input, formative research, user testing and feedback. Diverse teams (researchers, advocates and developers) participated including content refinement, identification of actors, and development of video scripts. Patient feedback was provided in the final production period and through a vanguard group (N=100) from the randomized trial. RESULTS: Patients/advocates confirmed barriers to cancer clinical trial participation, including lack of awareness and knowledge, fear of side effects, logistical concerns, and mistrust. Patients indicated they liked the tool's user-friendly nature, the organized and comprehensive presentation of the subject matter, and the clarity of the videos. CONCLUSION: The development process serves as an example of operationalizing best practice approaches and highlights the value of a multi-disciplinary team to develop a theory-based, sophisticated tool that patients found useful in their decision making process. Practice implications Best practice approaches can be addressed and are important to ensure evidence-based tools that are of value to patients and supports the usefulness of a process map in the development of e-health tools.

Developing a typology of African Americans with limited literacy based on preventive health practice orientation: implications for colorectal cancer screening strategies.

Preventive health messages are often tailored to reach broad sociodemographic groups. However, within groups, there may be considerable variation in perceptions of preventive health practices, such as colorectal cancer screening. Segmentation analysis provides a tool for crafting messages that are tailored more closely to the mental models of targeted individuals or subgroups. This study used cluster analysis, a psychosocial marketing segmentation technique, to develop a typology of colorectal cancer screening orientation among 102 African American clinic patients between the ages of 50 and 74 years with limited literacy. Patients were from a general internal medicine clinic in a large urban teaching hospital, a subpopulation known to have high rates of colorectal cancer and low rates of screening. Preventive screening orientation variables included the patients' responses to questions involving personal attitudes and preferences toward preventive screening and general prevention practices. A k-means cluster analysis yielded three clusters of patients on the basis of their screening orientation: ready screeners (50.0%), cautious screeners (30.4%), and fearful avoiders (19.6%). The resulting typology clearly defines important subgroups on the basis of their preventive health practice perceptions. The authors propose that the development of a validated typology of patients on the basis of their preventive health perceptions could be applicable to a variety of health concerns. Such a typology would serve to standardize how populations are characterized and would provide a more accurate view of their preventive health-related attitudes, values, concerns, preferences, and behaviors. Used with standardized assessment tools, it would provide an empirical basis for tailoring health messages and improving medical communication.

Perceived colonoscopy barriers and facilitators among urban African American patients and their medical residents.

African Americans suffer from higher colorectal cancer morbidity and mortality than do Whites, yet have the lowest screening rates. To understand barriers and facilitators to colorectal cancer screening, this study used perceptual mapping (multidimensional scaling) methods to compare patients' perceptions of colonoscopy and general preventive health practices to those of their doctors in a general internal medicine clinic in a large urban hospital. African American patients (n = 102) were surveyed about their own screening beliefs; third-year resident physicians (n = 29) were asked what they perceived their patients believed. The perceptual maps showed significant differences between the patients' and physicians' perceptions of barriers, facilitators, and beliefs about screening. Physicians believed logistical lifestyle issues were the greatest screening barriers for their patients whereas fears of complications, pain, and cancer were the most important barriers perceived by patients. Physicians also underestimated patients' understanding of the benefits and importance of screening, doctors' recommendations, and beliefs that faith in God could facilitate screening. Physicians and patients perceived a doctor's recommendation for screening was an important facilitator. Better understanding of patient perceptions can be used to improve doctor-patient communication and to improve medical resident training by incorporating specific messages tailored for use with African American patients.

Perceptions of colorectal cancer screening in urban African American clinic patients: differences by gender and screening status.

African Americans have higher colorectal cancer (CRC) morbidity and mortality than whites, yet have low rates of CRC screening. Few studies have explored African Americans' own perceptions of barriers to CRC screening or elucidated gender differences in screening status. Focus groups were conducted with 23 African American patients between 50 and 70 years of age who were patients in a general internal medicine clinic in a large urban teaching hospital. Focus groups were delimited by gender and CRC screening status. Focus group transcripts were analyzed using an iterative coding process with consensus and triangulation to develop thematic categories. Results indicated key thematic differences in perceptions of screening by gender and CRC screening status. While both men and women who had never been screened had a general lack of knowledge about CRC and screening modalities, women had an overall sense that health screenings were needed and indicated a stronger need to have a positive relationship with their doctor. Women also reported that African American men do not get colonoscopy because of the perceived sexual connotation. Men who had never been screened, compared to those who had been screened, had less trust of their doctors and the health care system and indicated an overall fear of going to the doctor. They also reiterated the sexual connotation of having a colonoscopy and were apprehensive about being sedated during the procedure. Overall, men expressed more fear and were more reluctant to undergo CRC screening than women, but among those who had undergone CRC screening, particularly colonoscopy, men expressed advantages of having the screening. All groups were also found to have a negative attitude about the use of fecal occult blood testing and felt colonoscopy was the superior screening modality. Results suggest that messages and education about CRC screening, particularly colonoscopy, might place more emphasis on accuracy and might be more effective in increasing screening rates among African Americans if tailored to gender and screening status.